US Supreme Court Upholds Affordable Health Care Act

[Bolty]

The U.S. Supreme Court on Thursday upheld the controversial health care law championed by President Barack Obama in a landmark decision that will impact the November election and the lives of every American.

In a 5-4 ruling, the high court decided the individual mandate requiring people to have health insurance is valid as a tax, even though it is impermissible under the Constitution's commerce clause.

"In this case, however, it is reasonable to construe what Congress has done as increasing taxes on those who have a certain amount of income, but choose to go without health insurance," Chief Justice John Roberts wrote in the majority opinion. "Such legislation is within Congress's power to tax."

The importance of the decision cannot be overstated: It will have an immediate and long-term impact on all Americans, both in how they get medicine and health care, and also in vast, yet-unknown areas of "commerce."

The most anticipated Supreme Court ruling in years allows the government to continue implementing the health care law, which doesn't take full effect until 2014.



As someone who fully expected the Supreme Court to strike the law down, color me surprised! Note: I support the law, by the way.

[kandrathe]

As someone who fully expected the Supreme Court to strike the law down, color me surprised! Note: I support the law, by the way.

It did come down to how the fee was described. If it is a tax, then Congress can impose a tax on people who do not elect to have a health insurance policy. What I believe it also implies is that Congress cannot fine you for not buying something, or force you to buy something against your will.

[Kevin]

I'm surprised by this as well.

I support health care reform. I support some of this law as well. In a way I was actually hoping that the supreme court struck down the public mandate portion. The reasoning for that is because there are a lot of things in the law that are popular, even amongst some of the more rabid "This is unconstitutional" folks. Mainly not being denied coverage if you have a pre-existing condition. So even the Republicans in Congress who want to get it repealed would be wary of just getting rid of everything.

Since insurance doesn't work without enough buy in and a public mandate would not be allowed had the court struck it down, the public option very likely would have ended up back on the table. I liked the public option. I think it would have saved money over what happens now with the government picking up uninsured emergency room visits already.

Another possibility would have been the expansion of medicare/medicaid which are essentially single payer public options but limited to age eligibility.

I still hope that the existing bill gets some changes and I think it will. Current political victories and climate aside, the bill will still get attacked, but the popularity of the changes it has and will create will help give momentum to better reform than what the current bill did/will do. Even in a divisive combative environment. I hope we will get to a public option solution. I don't think it will kill private insurance and I don't want to kill private insurance.

I do worry about what the decision means for the precedent it sets for expansion of governmental powers. I also really wish the Citizen's United decision had gone the other way too. I think they miss what needs to be done as far as governmental powers/regulation but on different places of the issues.

I'm very surprised by it too.

[Lissa]

I think the real surprise in all of this is that Roberts was the deciding vote instead of Kennedy (the one that always seems to break the ties). Outside of those two, I'm not surprised on how everyone else made their decisions.

[kandrathe]

I think the real surprise in all of this is that Roberts was the deciding vote instead of Kennedy (the one that always seems to break the ties). Outside of those two, I'm not surprised on how everyone else made their decisions.

While establishing the limits of the commerce clause was important, the lesser publicized but more important part of why the 26 States signed on to the challenge was the drastic increase in the size of Medicaid. What is unclear still is how the already revenue strapped States will come up with their portion of the requirement for funding Medicaid (or risk losing their federal portion).

The justices said the Constitution allows the states to have a choice on whether to expand the group of people who are eligible for Medicaid coverage, but if they decline, they cannot be penalized.

Pushing more people into Medicaid was the biggest portion of closing the gap on the uninsured. Now it is unclear if the uninsured gap will be closed, since this ruling will allow the States to determine Medicaid eligibility.

For example, "The Medicaid expansion portion of the Affordable Care Act was of major concern in Alabama, where nearly 1 million people get their health care through Medicaid and the expansion could increase that by more than 500,000 people. In other words, the state would go from 21 percent of its state population eligible for Medicaid to about 40 percent."

Where will those 500,000 Alabamians get insurance now -- or face possibly being taxed by the Federal government for not having insurance.

I liked the public option. I think it would have saved money over what happens now with the government picking up uninsured emergency room visits already.

First, I think the subject often convolute health care with health insurance, so I'm glad you are focusing on health insurance. In talking about insurance then, we also convolute the insurance costs of preventative maintenance with that needed for treating acute or chronic illness or injury. From the government concerns perspective (e.g. misusing the emergency room or hit by a car lying in the street), it would be best if every citizen had an insurance covering both the times when you've got the bad cough (and want to make sure it's not tuberculosis), and to prevent uninsured people dying in the streets from lack of anyone willing to care for another potential non-payer.

But... If those costs are hidden, either by having an employer, or the government pay the bulk of them, then there is not much consumer decision making that will help to drive the costs lower. What happens then when costs need to be controlled, is that either corporations, or governments will end up deciding what procedures, or health care is warranted based on age, based on quality of life, based on morbidity. I don't believe we have the capability of giving everyone 100% of the health care they might need to have their longest possible life span with the highest possible quality of life. The limitation is cost. I think I would rather choose how my portion is used, rather than a bureaucrat in a corporate insurance company, or a bureaucrat in some part of government.

For me, I think it is clear that we need to decouple insurance (or at least the basics) from employment, and we need to put people in charge of making more of their own health care purchase decisions. I think the method, and level of government subsidy is a secondary concern to establishing a system for a health care economy that isn't either heavily rationed or subject to runaway inflation.

[shoju]

I'm really torn on what I think of this bill.

Part of me thinks that "taxing" people for not having health care is a terrible idea. It sounds like a good idea, but if you are taxing them, it increases their burden, which means that it becomes harder to get to a position where they can afford health care.

But the other part of me, is husband to a type 1 diabetic, who has had the disease for 22 years. I know the costs, and I know how painful it is when the insurance company tells us that it's a pre-existing condition, and that we have to languish through a year with their insurance racking up super awesome bills before they will allow her to join their diabetes advantage program. With this new bill, that pain is lessened.

I don't know, I'm just not a big fan of the "tax / fine / pay money" because I can't afford to get insurance, so now I have to pay you more of the money that I don't already have.

[Lissa]

I think the real surprise in all of this is that Roberts was the deciding vote instead of Kennedy (the one that always seems to break the ties). Outside of those two, I'm not surprised on how everyone else made their decisions.

While establishing the limits of the commerce clause was important, the lesser publicized but more important part of why the 26 States signed on to the challenge was the drastic increase in the size of Medicaid. What is unclear still is how the already revenue strapped States will come up with their portion of the requirement for funding Medicaid (or risk losing their federal portion).

I'm not sure why your comment is attached to my comment since mine was more about a role reversal that probably no one saw coming (except for Roberts himself and maybe other Justices privy to his decision).

As to your actual comment, I think you misread the decision just like Fox and CNN both did. The part found unconstitutional was the ability of the Feds to cut the Medicaid funding of the States.

---

I'm really torn on what I think of this bill.

Part of me thinks that "taxing" people for not having health care is a terrible idea. It sounds like a good idea, but if you are taxing them, it increases their burden, which means that it becomes harder to get to a position where they can afford health care.

But the other part of me, is husband to a type 1 diabetic, who has had the disease for 22 years. I know the costs, and I know how painful it is when the insurance company tells us that it's a pre-existing condition, and that we have to languish through a year with their insurance racking up super awesome bills before they will allow her to join their diabetes advantage program. With this new bill, that pain is lessened.

I don't know, I'm just not a big fan of the "tax / fine / pay money" because I can't afford to get insurance, so now I have to pay you more of the money that I don't already have.

The real target is those that can afford it, but refuse to buy it. Those that are finacially strapped do have options through their state governments, especially those that are finacially disadvantaged (I saw that first had for 6+ years while living in Arizona and working for a Health Care Clinic that was designed to aid the disadvantaged).

[Quark]

I think the real surprise in all of this is that Roberts was the deciding vote instead of Kennedy (the one that always seems to break the ties). Outside of those two, I'm not surprised on how everyone else made their decisions.

So people reading the Dissent have said it sounds like it was written from a majority perspective. Add that with the pure strength of the opinion ("the entire act is unconstitutional"), there's speculation that Roberts was originally against but flipped due to the arguments others against were presenting.

Edit:

The part found unconstitutional was the ability of the Feds to cut the Medicaid funding of the States.

Existing funding, specifically. New funding presented as part of the Act can still be cut.

[kandrathe]

As to your actual comment, I think you misread the decision just like Fox and CNN both did. The part found unconstitutional was the ability of the Feds to cut the Medicaid funding of the States.

Well, no. The federal government picks up a large share for the first two years, but it would be insanity for anyone in certain state governments to toss out their States fiscal order to lap up two years of federal coercion. Some states have no issues, and had no need for Obama-care in the first place.

If we stay with Alabama, for example, the shortfall after 2 years would be at least $160 million, which equates to a 5% increase to their income tax.

[DeeBye]

Related

[Jester]

I'm not sure why your comment is attached to my comment since mine was more about a role reversal that probably no one saw coming (except for Roberts himself and maybe other Justices privy to his decision).

Roberts may be trying to build his reputation as beyond the partisan Bush vs. Gore era, and returning to a more purely "judicial" role as arbiter of the constitution. I don't think he likes the perception that he's just a political tool, and that the court is just politics by other means.

That's the cool thing about appointments for life. Politics may make the selections, but they can't determine where the justices' opinions will drift to.

-Jester

[Kevin]

For me, I think it is clear that we need to decouple insurance (or at least the basics) from employment, and we need to put people in charge of making more of their own health care purchase decisions. I think the method, and level of government subsidy is a secondary concern to establishing a system for a health care economy that isn't either heavily rationed or subject to runaway inflation.

I agree that insurance shouldn't be coupled to employment, which means people can choose their own, but I don't have an issue with the government being one of those options that they can choose, and I want the government to take a bit of money from me make sure those who don't have the same income potential/opportunities as myself get health care, both preventative and reactionary care.

Sure there will be people that abuse the system, humans are clever and/or lazy and they find ways to exploit anything. I simply accept that as part of the price I pay for the benefits of living in a structured society. I want that society I'm a part of to be as educated and healthy as possible. I want my government to provide some minimal levels of both (so public health care and public education options). I prefer those options to be as optional as feasible. I understand not everyone will agree on that minimal level and some feel it should be none, but I think those people should be educated on the benefits they get from living in a structured society and to try and evaluate what that might cost them for that value.

I'm trying to be careful to use the words structured society because like you I don't want that convoluted with freedoms/liberty. You have to pay a price in those areas for some of the structure too.

I worry that the balance, sometimes delicate balance, this all takes is not being met. But as I mentioned earlier, I'm glad that we have at least started down the road to reform because the system we have now is broken and change is hard to accept, and hard to accomplish. I'm aware this will take time, I still hope and belief things will work out well in the end. I didn't have that belief 15 years ago when I had my first realizations of how broken the current system was (and I was late to the party on that, but I was also only 22 at the time).

---

That's the cool thing about appointments for life. Politics may make the selections, but they can't determine where the justices' opinions will drift to.

Yep, I do think the current structure is a good one as far as the SCOTUS is concerned.

I'm no longer convinced that the House/Senate structure and methods of appointment are good. States are not as powerful as they used to be, I'm not sure they need to be, so I'm not sure we need two houses. Of course if the US could just fix the way we vote for the house and senate the design might start working more as it was intended/envision. I keep being told that many of the founders were against the idea of political parties. I'm not, but a voting system that doesn't drive everything to a two party state would be nice.

[kandrathe]

I agree that insurance shouldn't be coupled to employment, which means people can choose their own, but I don't have an issue with the government being one of those options that they can choose, and I want the government to take a bit of money from me make sure those who don't have the same income potential/opportunities as myself get health care, both preventative and reactionary care.

It's not clear to me where and when the "public concern" should stop. We don't want ambulance drivers scrutinizing ability to pay. We don't want infectious people spreading their illnesses to us healthy folks. We'd like to stamp out polio, tuberculosis, small pox, etc. through preventative health measures.

On the other side, there are cosmetic issues. And, there are self inflicted morbidities, like alcoholism, or obesity, or lung cancer due to smoking. To me, it's easier to manage these things when you put the burden of some decisions back onto the decision maker. It seems a bit harsh, but if you want to smoke, fine but don't expect us to pay for your emphysema or cancer treatments.

[Lissa]

I'm not sure why your comment is attached to my comment since mine was more about a role reversal that probably no one saw coming (except for Roberts himself and maybe other Justices privy to his decision).

Roberts may be trying to build his reputation as beyond the partisan Bush vs. Gore era, and returning to a more purely "judicial" role as arbiter of the constitution. I don't think he likes the perception that he's just a political tool, and that the court is just politics by other means.

That's the cool thing about appointments for life. Politics may make the selections, but they can't determine where the justices' opinions will drift to.

-Jester

Yes, this change, to me, reminded me very much of Judge Souter who G. H. W. Bush appointed thinking he was going to be a conservative force for the Bench and ended up being the exact opposite for most of his decisions.

---

I'm no longer convinced that the House/Senate structure and methods of appointment are good. States are not as powerful as they used to be, I'm not sure they need to be, so I'm not sure we need two houses. Of course if the US could just fix the way we vote for the house and senate the design might start working more as it was intended/envision. I keep being told that many of the founders were against the idea of political parties. I'm not, but a voting system that doesn't drive everything to a two party state would be nice.

This is getting off topic, but the cause for this can squarely be pointed back to the Seventeenth Amendment when Senators were no longer appointed by the governing bodies of the States, but instead changed over to direct election by the Populous. The original intent of the House and Senate was the House was to be the chamber of the Populous and the Senate was to be the chamber of the States. As soon as the Seventeenth Amendment was established, this made both chambers of Congress now representations of the Populous and took away some of the power from the States.

[DeeBye]

And, there are self inflicted morbidities, like alcoholism, or obesity, or lung cancer due to smoking. To me, it's easier to manage these things when you put the burden of some decisions back onto the decision maker. It seems a bit harsh, but if you want to smoke, fine but don't expect us to pay for your emphysema or cancer treatments.

There's a whole lot that this line of thinking leads to. Sports can be dangerous, so don't expect us to pay for your broken leg you suffered while skiing. Driving is dangerous, so don't expect us to pay for your injuries suffered in a collision. You didn't put sunscreen on? Have fun paying for your own skin cancer treatments. Where do you draw the line?

[kandrathe]

There's a whole lot that this line of thinking leads to. Sports can be dangerous, so don't expect us to pay for your broken leg you suffered while skiing. Driving is dangerous, so don't expect us to pay for your injuries suffered in a collision. You didn't put sunscreen on? Have fun paying for your own skin cancer treatments. Where do you draw the line?

Yes. I don't know.

It seems fair to me that there should be some limits on the governments deep pockets (tax payers -- or public debt) , no?

On the other hand, who gets to choose if your new baby gets an expensive open heart surgery to save its life.

[DeeBye]

It seems fair to me that there should be some limits on the governments deep pockets (tax payers -- or public debt) , no?

On the other hand, who gets to choose if your new baby gets an expensive open heart surgery to save its life.

These questions are so bizarre to me because I only have first-hand experience with Canada's universal system. When I read about your US system, it baffles me.

Doctors decide what treatment is performed, and no one asks "how much is this gonna cost?" There is no government bureaucrat deciding who lives and who dies while twirling his evil mustache.

So no, I don't think there should be limits on how much the government pays (through taxes collected) for necessary treatment, and I think doctors are the only ones who should decide what treatment is required.

[kandrathe]

These questions are so bizarre to me because I only have first-hand experience with Canada's universal system. When I read about your US system, it baffles me.

Doctors decide what treatment is performed, and no one asks "how much is this gonna cost?" There is no government bureaucrat deciding who lives and who dies while twirling his evil mustache.

So no, I don't think there should be limits on how much the government pays (through taxes collected) for necessary treatment, and I think doctors are the only ones who should decide what treatment is required.

Then I think everyone would opt to get everything possible.

"The federal government estimates that 70 percent of health-care expenditures are spent on the elderly, 80 percent of that in the last month of life -- and often for aggressive, life-sustaining care that is futile."

Half of the population spends little or nothing on health care, while 5 percent of the population spends almost half of the total amount. In 2002, the 5 percent of the U.S. community (civilian noninstitutionalized) population that spent the most on health care accounted for 49 percent of overall U.S. health care spending (Chart 1, 40 KB). Among this group, annual medical expenses (exclusive of health insurance premiums) equaled or exceeded $11,487 per person.

In contrast, the 50 percent of the population with the lowest expenses accounted for only 3 percent of overall U.S. medical spending, with annual medical spending below $664 per person. Thus, those in the top 5 percent spent, on average, more than 17 times as much per person as those in the bottom 50 percent of spenders

http://www.ahrq.gov/research/ria19/expendria.htm

[DeeBye]

Then I think everyone would opt to get everything possible.

"The federal government estimates that 70 percent of health-care expenditures are spent on the elderly, 80 percent of that in the last month of life -- and often for aggressive, life-sustaining care that is futile."

Either we are discussing apples and oranges, or you misunderstand the Canadian healthcare system and my opinion on how healthcare should operate in a first-world country. I cannot walk into my doctor's office and demand a free MRI just because "free healthcare". Doctors have the ultimate say on what treatment is administered (as I said more than once in my previous post).

I visit my doctor for checkups or when I have a medical issue. He decides on treatment, and that's it. I can discuss optional treatments with him, but my doctor is the ultimate arbiter.

People with access to free healthcare do not rush to their closest hospital for whatever free stuff they can get. They go there when they need to, because no one likes going to a hospital.

[ShadowHM]

Either we are discussing apples and oranges, or you misunderstand the Canadian healthcare system and my opinion on how healthcare should operate in a first-world country. I cannot walk into my doctor's office and demand a free MRI just because "free healthcare". Doctors have the ultimate say on what treatment is administered (as I said more than once in my previous post).

I visit my doctor for checkups or when I have a medical issue. He decides on treatment, and that's it. I can discuss optional treatments with him, but my doctor is the ultimate arbiter.

People with access to free healthcare do not rush to their closest hospital for whatever free stuff they can get. They go there when they need to, because no one likes going to a hospital.

There may well still be some sources of extra cost due to the doctors being the gateway, especially when there are some serious conflicts of interest possible in the private health care sector. We Canucks don't have that concern or that cost because the hospitals are not privately owned, although some clinics do offer 'full-service' and hence may still over-prescribe on testing.

I now work in a peripheral area of healthcare, and thus receive a number of newsletters that are targeted to Canadian physicians on healthcare topics. I got an email at work yesterday from Parkhurst Exchange. Here was their take on the news of the SCOTUS decision:

OBAMACARE LIVES ON!
In a decision that has bowled over most expert prognosticators, the US supreme court has upheld the centrepiece of President Obama's signature healthcare legislation, the individual mandate that compels millions of Americans to buy health insurance. The Affordable Care Act, popularly known as Obamacare (or Obamneycare in some circles) came through its months-long ordeal slightly singed at the edges but largely intact, and the next 18 months will see a good deal of its provisions implemented.

Much ink will be spilled dissecting the ruling and its implications for healthcare, spending, and of course the upcoming US election. But perhaps the most telling indicator is the market reaction: shares in for-profit hospitals jumped while health insurers' stock fell sharply. This reflects the growing belief among more engaged observers on left and right that Obamacare isn't really going to support a viable health insurance industry, because it's really a halfway house on the road to a single-payer system.

Private insurers aren't directly to blame for the upward spiral in US health costs. They don't want more expensive procedures any more than they want more floods and hurricanes. Perverse incentives and naked greed on the part of many US hospitals and doctors play a more direct role. But private insurers are a middleman that needs to be gotten out of the way if the government is ever to get to grips with those doing the billing. There is no doubt that Obamacare will shrink their margins from day one, and the squeeze is only likely to get tighter. Insurance companies will be encouraged to lose interest in the health marketplace – leaving room for the public option to step in.

For the best explanation we've seen of the real nature of America's health cost problem, read this great investigation by Harvard Medical School professor Atul Gawande. During the tense passage of the 2009 bill, Obama was rarely to be seen without a copy of this article. He cited it frequently and handed out dozens of photcopies to White House staffers. It provides the most direct insight we have into Obama's thinking on healthcare. It may make uncomfortable reading for many American doctors.